Provider Demographics
NPI:1972840064
Name:SEDRA MEDICAL CLINIC PLC
Entity Type:Organization
Organization Name:SEDRA MEDICAL CLINIC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAZEM
Authorized Official - Middle Name:
Authorized Official - Last Name:SEDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-683-5137
Mailing Address - Street 1:213 LABREE AVE N
Mailing Address - Street 2:SUITE #207
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2022
Mailing Address - Country:US
Mailing Address - Phone:218-683-5137
Mailing Address - Fax:218-683-5413
Practice Address - Street 1:213 LABREE AVE N
Practice Address - Street 2:SUITE #207
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2022
Practice Address - Country:US
Practice Address - Phone:218-683-5137
Practice Address - Fax:218-683-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1669408753OtherINDIVIDUAL NPI
MN590610500Medicaid
MNIO3510Medicare UPIN
MN590610500Medicaid